Virtual reality improves the effectiveness of digital psychoeducation by modulating emotion regulation in dementia caregivers

Background: Informal caregivers of people with Alzheimer’s disease (AD) are exposed to persistent psychological distress, which negatively affects both caregiver health and care quality care. Although digital psychoeducational interventions improve access to support, their effects on emotional processing and long-term mental health outcomes remain heterogeneous. This study assessed whether integrating virtual reality (VR) experience into digital psychoeducational intervention enhances engagement, directly targets emotion regulation mechanisms, and strengthens mental health of caregivers of people with mild-to-moderate AD. Methods: This randomized controlled trial compared standard digital psychoeducation with VR-enhanced digital psychoeducation delivered over six weeks (ClinicalTrials.gov ID: NCT05780476). Outcomes were assessed at baseline (T0), post-intervention (T1), and 2-month follow-up (T2). Measures included anxiety (STAI-Y), burden (ZBI), depression (BDI-II), emotion regulation (ERQ), and self-efficacy (RS-CSE). Data were analyzed using generalized linear mixed models for repeated measures; age and education were included as covariates. Bonferroni-adjusted post-hoc comparisons were applied. Results: A total of 118 caregivers completed baseline assessments (psychoeducation: n=57; VR-based psychoeducation: n=61). Attrition between T0 and T1 was low (7%), with comparable retention across intervention arms. Caregivers were predominantly female (77%) and adult children (66%), with a mean age of 56±11 years. At T0, groups were comparable for gender, relationship, co-residence, anxiety, depression, and perceived stress (all p>0.10), although the VR group was slightly younger (p=0.04) and more educated (p=0.03). Both groups benefited from participation, with significant reductions in anxiety (p<.001), burden (p=.008), and depressive symptoms (p=.002), together with improvements in self-efficacy (p=.010). VR-enhanced psychoeducation demonstrated a distinct mechanism-specific added value. A significant group×time interaction emerged for expressive suppression (ERQ-S, p=.014), with VR participants showing reduced reliance on maladaptive emotion regulation strategies, while controls showed minimal change. VR also improved self-efficacy for controlling upsetting thoughts (RS-CSE-OR: p=.040). At T2, these changes translated into superior medium-term outcomes in the VR group, including greater reductions in depression (ΔT0-T2=-2.3, p=.015) and burden (ΔT0-T2=-3.5, p=.038). Conclusion: VR-enhanced digital psychoeducation improves caregiver mental health by selectively targeting emotion regulation mechanisms that support sustained reductions in burden and depressive symptoms. High caregiver engagement and durable clinical benefits highlight VR as a valuable component of scalable digital interventions for caregiving.